Archive for October, 2015

Change rarely comes easily. People get used to doing things a certain way, and physicians are no exception. One such shift was a technology Kaiser Permanente adopted early on, creating patient medical records electronically rather than on paper.

In 2013 I interviewed Jim Gersbach, senior hospital communications consultant for Kaiser Permanente’s Northwest region. As their unofficial historian, Jim had accumulated many stories during his 28 years of service. This is an edited version of one of his learnings.

“EpiCare was forcing [doctors] to actually enter data on every patient; they couldn’t just leave it blank.” -Jim Gersbach

I’ve been able to see decisions made and then see them evolve over time, and whether those were good decisions, or not, and how they played out 10, 15, or even 20 years later. A lot of friends that I know, they work for a company, they work really hard, they try things, they innovate for two, three years, and then they move on. And they never really know what the long term impacts of those decisions were.

I’ve had the opposite experience. I’ve been able to see innovations and policies that were introduced; I could then see if they really did pan out, and hold up, and stand the test of time.

This example is from an article I wrote in 1996 for our employee publication. I was talking with Dr. Michael Krall, one of our physicians working on a beta pilot project at the Sunset Medical Office. He had a desktop computer, and he said that they were working on this EpiCare product, and it was going to change the face of healthcare. I said ‘Oh, well how’s it work?’

Prior to that, we had computerized lab records, computerized this, computerized that. But you had to go and get those records sent to you, and it was not all integrated the way it is now. It was interesting, from that one discussion of them beta testing in that one medical office, to then see that it later succeeded, and they made the decision to roll it out to the Northwest. Then they gradually put all of Kaiser Permanente’s systems onto EpiCare.

I can remember some of the older doctors didn’t even know how to type. That was the biggest barrier; they were doing the old hunt-and-peck because they had never needed to type. They just did dictation, or their nurses would type it up for them. The younger physicians were very eager to adopt computerized medical records, because they were a little bit more familiar with computers.

But after 1998 the Northwest Permanente Medical Group had done some survey work – [which had some] pushback— and heard that ‘This is adding to our day; it’s 45 minutes more a day to try and enter all this stuff in.’ People were complaining that ‘When I did paper, I didn’t take so long to do all this stuff, so it’s not a time saver for us.’

We started looking at that, and found was that sometimes when doctors would get busy, they would just sort of scribble something illegible in the chart, and send it off, because they could get out of their office faster. EpiCare was forcing them to actually enter data on every patient; they couldn’t just leave it blank. That was a major ‘Aha!’ moment. What became evident was, ‘Wait a minute; we’re not necessarily charting everything we’re supposed to.’ And the computerized system actually helped.

Not only did it make everything legible, but it forced clinicians to put something in; you had to type something in, or it wouldn’t advance you forward. It definitely improved the quality of the data.

In the Northwest, at the time EpiCare was being adopted, the doctors were very free to say what they didn’t like about it. But despite all the grumbling about ‘It’s adding to our length of day,’ when we asked, “Would you ever want to go back to paper?” they said ‘Absolutely not! I couldn’t live without the system, because it actually provides me everything I need to know for the patient.’ They very quickly saw the value of it as a clinical aid.

Sloan served as president, chairman, and CEO of the General Motors Corporation from the 1920s through the 1950s. He led GM to become the largest corporation on earth and is credited with improving automobile technology and offering the public a choice of colors and styles (a positive spin on the invention of planned obsolescence).

Henry J. Kaiser’s role in dam and ship building was credited in the Forbes paean, only to set the stage for the big ticket item:

“But perhaps his greatest feat was providing his workers with health care coverage. Kaiser saw his prepaid health coverage plan as a way to temper labor unrest and leave the government out of the process, while bettering humanity. He made public campaigns haranguing fellow business leaders to follow his lead. Kaiser’s vision spawned the U.S. health care industry.”

While it’s arguable that Kaiser “saw his prepaid health coverage plan as a way to temper labor unrest” (he’d long before learned the benefits of proactive cooperation with labor), the rest of the description is accurate. The man could be a contrarian.

This photo of the two industrial giants together was published in the weekly Kaiser Richmond shipyard newspaper Fore ‘n’ Aft, August 25, 1944. At the time, Henry Kaiser was the most prolific private shipbuilder in the world, yet here he is, proudly showing off the two-year-old Oakland Permanente Foundation hospital that cared for shipyard workers.

“Emmy Lou Packard: Drawing New Conclusions in the Kaiser Shipyards”Lincoln Cushing, Kaiser Permanente ArchivistPart of current exhibition at Rosie the Riveter National Park, Richmond, Calif., on display through 2015Saturday, November 21, 11:00-12:00Wednesday, December 9, 2:00-3:00 pm
Free and open to the public. Contact the park to reserve seats, space is limited.

Emmy Lou Packard illustration, 2/22/1945

Two slideshow presentations which amplify the exhibition theme – the challenges of labor journalism during a time when the entire work force was changing. Packard’s illustrations in the weekly Kaiser Richmond shipyard newspaper Fore ‘n’ Aft were patriotic without resorting to racist jabs or stereotypes; she portrayed workers with dignity and character. She drew women’s experiences from a woman’s point of view – numerous vignettes show children (one of her regular subjects later in life), shopping, home life, and the challenges of survival and adjustment in a tempestuous time.

“More Than War Ships: Kaiser’s WWII Legacies in Healthcare, Childcare, Housing, and Environment”Lincoln Cushing, Kaiser Permanente Archivist, with Dr. Jeffery Sanders, WSUThursday, October 15, 7 pm – 9 pm
Part of current Oregon Historical Society exhibition (Portland, Oregon)
“World War II: A World at War, A State Transformed”
Free and open to the public

Child Service Center, Kaiser Oregon shipyards

Kaiser Permanente historian Lincoln Cushing will present “Henry J. Kaiser’s World War II Home Front Legacy,” a slide show about the innovative support systems Kaiser built for wartime production workers, including child care centers, housing, transportation, and health care. Although Henry J. Kaiser earned the sobriquet “Patriot in Pinstripes” for his industrial contributions to the Allied military effort during World War II, it can be argued that his most enduring legacy was his comprehensive suite of Home Front social benefit programs. He will co-present with Dr. Jeffery Sanders, Washington State University.

Article about valuable role of Physical Demands and Capacities Analysis, 6/1/1944

By now, everyone’s heard the jokes about the new International Classification of Diseases, the disease and health problem taxonomy standard managed by the World Health Organization. ICD is the latest in a series of efforts to classify diseases, starting in the 1850s. Originally called the International List of Causes of Death, the WHO assumed responsibility for the ICD when the organization was created in 1948. ICD version 10 (or ICD-10) is the newest code set. October 1 is the date on which ICD-10 compliance is required by the Centers for Medicare and Medicaid Services.

With 68,000 discrete diagnosis codes (as opposed to the previous 14,000), we are now able to define diagnoses at a very precise level of detail. Very, very, precise – such as “V97.33XD: Sucked into jet engine, subsequent encounter” or “Y92.146: Swimming-pool of prison as the place of occurrence of the external cause.” Yes, these are actual codes.

But, jokes aside, precise classification has its merits. It strengthens the storage and retrieval of diagnostic information for clinical, epidemiological and quality purposes. ICD descriptors also provide the basis for the compilation of national mortality and morbidity statistics. Kaiser Permanente has actively joined other health care providers in this massive project.

However, Kaiser health care practitioners during World War II were also trying to use precise descriptions to improve health, in a slightly different way.

Sample page from Physical Demands and Capacities Analysis

In May, 1944, the 627-page dense tome Physical Demands and Capacities Analysiswas published as a joint project of the Kaiser Foundation Hospitals and the Occupational Analysis and Manning Tables division of Region XII War Manpower Commission. The physician in charge of the study was Clifford Kuh, MD.

One of the primary goals of the Analysis was to make sure that individuals were assigned to jobs which they could perform without risk to their health. The study detailed 617 distinct job titles in the shipyards, from “Asbestos Worker, Cutter” to “Window Cleaner.” Although the Richmond shipyards did have the opportunity to use pre-placement physical examinations prior to hiring, the study provided the basis for accurate review of work-related health problems and suggestions for reassignment. During a short three-month survey period, only three workers had to leave their assigned job due to physical failure. During the four war years Kaiser’s yards employed almost 200,000 people.

An article in the Call Bulletin touted the survey, quoting William K. Hopkins, regional director of the United States War Manpower Commission:

“While the study has in mind the placement of all workers, the technique on which it is based will be invaluable in the post-war period – when tens of thousands of returning service men and women will have to be fitted into new jobs. I am particularly impressed with the study’s positive approach in emphasizing what a worker has the physical capacities to do, rather than the handicaps, often minor, which tend to prejudice his employment.”

Kaiser Permanente, building and using precise medical data for social benefit since 1944.